Create 50 Soap notes. Avoid repeating diagnosis. This needs to be from an FNP new grad perspective. Include a variety of preventive visits,acute, chronic, and wellness disorders.
Documentation Requirements
Must Include
Patient Demographics Section:
Age
Race
Gender
Clinical Information Section:
Time with Patiento Reason for visito Chief Complainto Social Problems Addressed
Medications Section:o # OTC Medications taken regularlyo # Prescriptions currently prescribedo # New/Refilled Prescriptions This Visit
ICD 10 Codes Category:o Include for each diagnosis addressed at the visit
CPT Billing Codes Category:o Include Evaluation and management codeo Provider procedure codes (pap smear, destruction of lesion, sutures, etc.)
Other Questions About This Case Category:
o Age Range
o Patient typeo HPIo Patients Primary Languageo Did you chart on the patient record?o Discussed Management with the Preceptoro Handled Visit Independentlyo Preceptor Present During Visit
Clinical Notes Category :
PLEASE follow this format
ChiefComplaint: “***”DIAGNOSIS: PLAN: Diagnostics: Therapeutics:Education:
Consultation/Collaboration:
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